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Measuring Up to Quality Standards

smiling patient

Hospitals across the country are challenged to meet quality standards based on practices known to result in the best outcomes for patients in four categories: surgical care, the treatment of heart failure, pneumonia, and acute myocardial infarction (heart attack).

"Improvement and consistency are essential for meeting our high standards," said Dr. Michael Kulisz, KishHealth System's chief medical officer.

During calendar year 2015:

  • Kishwaukee Hospital's composite score for the four inpatient areas remained consistent at 99.7%.
  • Valley West Hospital's composite score was 99.3%.
  • There were 0 ventilator-acquired pneumonia cases at Kishwaukee Hospital.
  • There were 0 catheter-related blood stream infections or catheter-related urinary tract infections at Valley West.
  • The surgical site infections rate for both hospitals was <1%.

Our Hospitals Accredited by The Joint Commission

The Joint Commission, which grants accreditation to healthcare organizations, conducts regular unannounced surveys of the KishHealth System hospitals, Kishwaukee Hospital in DeKalb and Valley West Hospital in Sandwich.

The Joint Commission has continuously accredited Kishwaukee Hospital since 1976. Its last Joint Commission survey was in 2016. In 2014 Kishwaukee Hospital added a Disease Specific Certification for both Knee and Hip Joint replacement. Valley West Hospital has been continuously accredited by The Joint Commission since 2003. Its last Joint Commission survey was in 2015. In 2016 both KishHealth System Home Care and KishHealth System Hospice became accredited by The Joint Commission.

The purpose of Joint Commission surveys is to evaluate an organization’s compliance with nationally established standards. Survey results are used to determine whether, and the conditions under which, accreditation should be awarded to the organization. The Joint Commission standards address organizational quality, safety-of-care and the safety of the environment in which care is provided. Anyone believing that he or she has pertinent and valid information about such matters may contact either hospital’s administrative offices. If anyone continues to have concerns, The Joint Commission can be contacted at:

The Joint Commission National Quality ApprovalDivision of Accreditation Operations

Office of Quality Monitoring
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181

Phone: 800.994.6610


KishHealth System will not take any disciplinary or retaliatory action against any employee (including, but not limited to physicians, staff, volunteers and students) reporting safety or quality of care concerns to The Joint Commission. This notice is posted in accordance with The Joint Commission's accreditation participation requirements.

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